Poor communication and failure to share a mutual understanding (i.e. shared cognition) of patient clinical goals between healthcare providers is associated with medical errors and adverse outcomes in medically complex older patients during transitions of care. Elderly patients with surgical conditions are particularly at risk, givn that critical information related to their chronic and acute clinical goals must be communicated between surgical and primary care providers (PCPs) who are typically located in separate care settings (i.e. inpatient versus outpatient settings) and may have different expectations of care. Communication of clinical goals and expectations of care between these providers within existing health information technology (IT) systems relies upon the one-way exchange of information (i.e. clinical summaries within electronic medical record), but does not allow for shared cognition among providers caring for the same patient. The objective of this project is to identify gaps in how surgical providers and PCPs communicate and share their expectations for the care of medically complex older patients during care transitions before and after surgery, and then use this information to help design a health IT communication tool that promotes shared cognition and better alignment of patient care goals between health care providers from different specialties. To address these goals, this project will use mixed methods to carry out two specific aims. First, we will characterize modes of communication (how, when, what, and where) and contextual factors related to how surgical providers and PCPs communicate their goals (i.e. clinical and functional goals) and expectations for the care of medically complex older patients during care transitions before and after surgery. This aim will use qualitative methods including ethnographic observation procedures and a cognitive task analysis to assess how clinical goals are documented and communicated between inpatient and outpatient providers before and after surgery, and to evaluate the extent of shared cognition of these goals between providers in different care settings. Second, we will use the results from the aim above and apply these findings to the design of a high-fidelity prototype health IT communication application based on the principal of shared cognition. This tool will be designed to allow providers from different specialties (e.g. surgeons and PCPs) to share a mental model of patient care, and be able to align and distribute goals and expectations for the care of medically complex older patients among each other. We will refine this health IT application through iterative feedback and formative evaluation by provider end-users. Improving communication and shared cognition between health providers using health IT applications has the potential to prevent medical errors and improve the outcomes of older patients undergoing a broad range of surgical procedures.